Title of the Article-Intestinal Gas

Acta Scientific Gastrointestinal Disorders (ISSN: 2582-1091) Volume 2 Issue 7 September 2019 Mini Review

Premashis Kar1* and Sushil Kumar Sharma2 1Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, UP, India 2Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, UP, India *Corresponding Author: Premashis Kar, Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, UP, India. Received: July 26, 2019; Published: August 14, 2019

Abstract Intestinal gas is mainly composed of nitrogen,ooxygen,carbon dioxide,hydrogen and methane.Various complaints attributed to

it are belching, flatulence abdominal bloating and abdominal distension. In patients with isolated symptoms of excessive belching, (GERD) and functional dyspepsia.We should always rule out alarm features in evaluation of patients such as weight loss,bleeding psychological and behavioral factors play an important role..Belching is also associated with gastroesophageal reflux disease per rectum,nocturnal abdomen pain diarrhoea and investigate further. Rome IV criteria for establishing the diagnosis of functional bloating should be used. Manangement of various disorders due to intestinal gas include education, treatment of associated disorders,

behavioralKeywords therapy,: dietary modifications and drugs. Intestinal Gas; Belching; Flatulence; Abdominaldistension; Bloating

Abbreviations jects and individuals who complain of gaseous distention [1]. Ni- trogen (N ), oxygen (O ), carbon dioxide (CO ), hydrogen (H ), and N2: Nitrogen; O2: Oxygen; CO2: Carbon Dioxide; H2: Hydrogen; 2 2 2 2 methane (CH ) account for more that 99 percent of expelled intes- - 4 tinal gas [1]. The composition of gas within the intestinal tract is - CH4: Methane; GERD: Gastroesophageal Reflux Disease; FOD predominantly N [1]. Oxygen is present in very low concentrations, rides and Polyols 2 MAPS: Fermentable Oligosaccharides Disaccharides Monosaccha and the concentrations of CO2, H2, and CH4 vary among individuals. Introduction Sources of intestinal gas Gastrointestinal complaints are commonly attributed by the Air swallowing patient to gas. Excessive intestinal gas occur due to excessive air Aerophagia is the major source of stomach gas. Larger amounts swallowing, increased intraluminal production from malabsorbed are swallowed when food is gulped. Aerophagia can be a manifesta- nutrients, decreased gas absorption due to obstruction or dysfunc- tion of anxiety, and is increased with gum chewing and smoking. tional gas clearance, or expansion of intraluminal gas due to chang- Most swallowed air appears to be eructated [2]. Swallowed air is es in atmospheric pressure.

the major source of O2 and N2 - Volume and composition of intestinal gas ence the amount of swallowed air passing from the stomach into in intestinal gas. Posture may influ The volume of gas in the intestinal tract is approximately 200 the small intestine. The supine position causes gastric air to pass mL in both the fasting and postprandial states in both normal sub-

Citation: Premashis Kar and Sushil Kumar Sharma. “Title of the Article-Intestinal Gas”. Acta Scientific Gastrointestinal Disorders 2.7 (2019): 16-20. Title of the Article-Intestinal Gas

17 preferentially into the small intestine as gastric air is located above In patients with isolated symptoms of excessive belching, psy- liquid gastric contents that overlie the gastroesophageal junction. chological and behavioral factors play an important role. Belching

Intraluminal production functional dyspepsia [9]. is also associated with gastroesophageal reflux disease (GERD) and , H , and CH , are produced 2 2 4 Diagnostic approach within the bowel lumen. Three of the five principal gases, CO Evaluation

• CO2: CO2 is derived from digestion of fat and protein in the Belching disorder is a functional syndrome, and the diagno- upper gastrointestinal tract, from bacterial fermentation sis is based on a history. Observation of air swallowing provides of intraluminal substrates, or may be liberated from supportive information. Patients who complain of isolated exces- the interaction of acid and bicarbonate [3]. Much of the sive belching are more likely to suffer from excessive uncontrolled CO2 produced in the upper small intestine is probably supragastric belching, and from episodes of frequent belching in absorbed before it reaches the colon. CO2 that is present in flatus is likely due to bacterial fermentation reactions in which they may belch up to 20 times per minute.

the colon. Increased CO2 in flatus can result from specific dietary substrates, such as nondigestible carbohydrates The presence of alarm features including weight loss, abdomi- [4]. nal pain, dysphagia, heartburn, and regurgitation are an indication for further diagnostic evaluation with upper endoscopy and/or im- • H2: H2 is both produced and consumed by fecal bac-

teria; the net H2 excretion is determined by these two aging (eg, abdominal computed tomography (CT) scan).

processes. H2production occurs predominantly in the colon [5]. Ingested carbohydrate and protein are sources Diagnostic criteria for functional belching

for H2 production. In healthy individuals, certain foods with high concentrations of oligosaccharides found in as bothersome (ie, severe enough to impact usual activities) belch- legumes, or resistant starches (flours made from wheat, According to the Rome IV criteria, belching disorder is defined oats, potatoes, and corn), cannot be completely digested ing from the esophagus or stomach more than three days a week by enzymes within the normal small bowel, leading to [10] increased H production [6]. with symptom onset at least six months before diagnosis. 2 . These criteria should be fulfilled for the last three months • Methane: Methane, like H , is exclusively a product of 2 Management bacterial metabolism. The presence of bile acid in the colon also may be important in the regulation ofmetha- • Education, treatment of associated disorders, and nogenesis [7]. behavioral therapy: Management includes education to decrease air swallowing and reassurance that belching is • Causes of increased intestinal gas: When excessive intestinal gas occurs, it may be due to excessive air discontinuation of gum chewing, smoking, drinking car- swallowing, increased intraluminal production from bonateda benign beverages,condition. Specificand gulping behavioral foods and measures liquids. include In pa- malabsorbed nutrients, decreased gas absorption due tients with underlying depression or anxiety, treatment to obstruction, or expansion of intraluminal gas due to should be initiated [11]. Patients with co-existing acid changes in atmospheric pressure. - ment of GERD. Clinical manifestations of intestinal gas reflux may require acid suppressive therapy for manage Belching Successful treatment of excessive belching by a therapist (eg, cognitive behavioral therapist or speech therapist) with special training in diaphragmatic breathing tech- from the esophagus or the stomach into the pharynx [8]. It may Belching or eructation is defined as an audible escape of air niques has been associated with a reduction in symptoms be voluntary or involuntary. Involuntary belching typically follows in small observational studies [12,13]. a meal and is caused by the release of swallowed air after gastric • Reflux inhibitors for refractory symptoms: Ba- distention. Belching is only considered a disorder when it is exces- clofen (10 mg three times daily) by reducing transient sive and becomes troublesome. lower esophageal sphincter relaxations and centrally suppressing the swallowing rate, may decrease both supragastric and gastric belching [14].

Citation: Premashis Kar and Sushil Kumar Sharma. “Title of the Article-Intestinal Gas”. Acta Scientific Gastrointestinal Disorders 2.7 (2019): 16-20. Title of the Article-Intestinal Gas

18 Flatulence - MAPs) [17,18]. The volume of gas passed per rectum varies from about 500 charides, disaccharides, monosaccharides, and polyols (FOD to 1500 mL per day [15] • Other interventions – Other interventions that have not consistently demonstrated efficacy in the prevention or between 10 and 20 times per day in healthy subjects [16]. Most . The frequency of flatus released varies management of flatulence include anti-flatulence medications (eg, simethicone and activated charcoal) and alpha-galactosi- individualsDiagnostic whoevaluation report excessive flatulence fall within this range. dase enzyme preparation [19,20].

Bismuth subsalicylate reduces the odor arising from hydrogen guided by the history and physical examination. A dietary history Evaluation of the patient complaining of flatulence should be [21]. should be obtained with a focus on gas-producing foods and beverages. sulfideAbdominal as well bloating as other and pungent distension components of flatus

Alarm features Bloating refers to a sensation of abdominal fullness, pressure, or a sensation of trapped gas, whereas distention is a measureable increase in abdominal girth. Bloating and distension have been re- Alarm• featuresNocturnal in patients abdominal with painflatulence include the following: ported in 20 to 30 percent of the general population and in up to 96 • Weight loss percent of patients with irritable bowel syndrome (IBS) [22-24]. • Hematochezia • Systemic symptoms including weight loss or fever Evaluation • Diarrhea or steatorrhea Bloating and distension may be caused by organic disease or • Vomiting other functional gastrointestinal disorders. A clinical diagnosis of • Severe abdominal tenderness, organomegaly, or - succussion splash on physical examination. tom-based diagnostic criteria and a limited evaluation to exclude functional bloating/distension requires the fulfillment of symp underlying organic disease. as diarrhea and abdominal pain should be evaluated for malab- Diagnostic criteria for functional bloating/distension New onset of flatulence associated with alarm symptoms such sorption. Stool examination for fat and Giardia, breath tests for Rome IV criteria for establishing the diagnosis of functional small intestinal and lactose intolerance, celiac serology, and en- bloating include both of the following (for at least three months doscopic evaluation. In the absence of alarm features, additional with symptom onset at least six months prior to diagnosis) [25]. evaluation is not required. • Recurrent bloating or distension, on average, at least one Management day per week; abdominal bloating and/or distension predominates over other symptoms include: • - Several measures that can be undertaken to reduce flatulence stipation, functional diarrhea, or postprandial distress Insufficient criteria for a diagnosis of IBS, functional con • Treatment of the underlying cause – In individuals syndrome. with lactose intolerance, management includes lactose restriction and the use of enzyme preparations that are Mild pain related to bloating may be present as well as minor taken orally with lactose-containing foods. In patients bowel movement abnormalities. with small bowel bacterial overgrowth, treatment is with antibiotic therapy Management • Dietary modification – Patients should be advised to • Dietary and lifestyle modification: Approach to treat- avoid gas-producing foods (eg, cabbage, onions, broc- ment of abdominal bloating and distension is similar to coli, brussel sprouts, wheat, and potatoes). In patients that used in patients with IBS. Patients are advised to

gas-producing foods, a diet low in fermentable oligosac- celery, carrots, raisins, bananas, apricots, prunes, Brus- without a significant improvement despite exclusion of avoid foods that increase flatulence (eg, beans, onions,

Citation: Premashis Kar and Sushil Kumar Sharma. “Title of the Article-Intestinal Gas”. Acta Scientific Gastrointestinal Disorders 2.7 (2019): 16-20. Title of the Article-Intestinal Gas

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Citation: Premashis Kar and Sushil Kumar Sharma. “Title of the Article-Intestinal Gas”. Acta Scientific Gastrointestinal Disorders 2.7 (2019): 16-20.